Basics of Facet joint injection

1. Facet Joint Injections
Comments
Mohamed M. Mohi Eldin,
Professor of Neurosurgery,
Faculty of Medicine,
Cairo University
One-Day Spine Clinic 1st workshop & hands-on
March 2nd 2016

2. FACET JOINT INNERVATION
It is important to note that it has a richly
innervated capsule and the medial branches
of the posterior lumbar rami provide this
innervation

3. Normal Facet Joints
Joint Space
Joint Margins
Articular cartilage
Periarticular soft
tissues

4. Degenerative FACET JOINT

5. Degenerative FACET
Articular cartilage loss
Subchondral bony
irregularities
Marginal hypertrophic
changes, spurring
Effusion
Atrophy of multifidi and
erector spnae muscles

6. Advanced Facet Disease
Absence of cartilage
Bone on Bone
Marginal hypertrophic
changes
Deconditioning of
multifidi and erector
spinae ms

7. CT scan of a patient with spinal canal stenosis
at the level of L5 due to facet joint arthrosis

8. Unilateral Facet Disease
• Left side normal
• Right side
– Articular cartilage
loss
– Joint Effusion

9. Unilateral Facet inflammation
• Articular cartilage
• Gadolinium
contrast
enhancement
– Medullary bone
marrow
– Periarticular soft
tissues

10. Facet Synovitis
• Prominent effusion
• Note: medial
ligamentum flavum
hypertrophy
• Paraspinous muscles
preservered

11. Facet Tropism

12. Paravertebral Soft Tissue
• Gadolinium
contrast
enhancement
– Periarticular soft
tissue
– Medullary bone
marrow
• High clinical
correlation with
pain generator

13. Facet Marrow
Edema
• Medullary bone
marrow edema
• Indicator of
inflammation
• High clinical
correlation with pain
generator

14. Facet Joint Injections

15. Clinical signs and radiologic appearance
in accordance

16. Diagnostic Facet Joint Injections
Facet joint injection and/or facet nerve block
(e.g. medial branch block) is proven and
medically necessary when used to localize
the source of pain to the facet joint

17. Diagnostic Facet Joint Injections
Is not recommended in patients with:
Neurologic abnormalities
More than one pain syndrome
Definitive specific diagnosis other than facet joint syndrome
Previous spinal surgery at the clinically suspected levels

18. Therapeutic facet joint injection
is unproven and not medically necessary for
the treatment of chronic spinal pain.
(pain lasting more than 3 months).

19. Facet block
Is an injection of local anesthetic and/or steroids into
or near the facet joint
Use of diagnostic blocks with injection of local
anesthesia into the facet joints or around the medial
branch nerves to identify the possible sources of
spinal pain is an established diagnostic procedure.
In a positive response, pain relief occurs but lasts
longer with the long-acting anesthetic.
Single lumbar facet joint diagnostic block had a 38%
false-positive rate.

21. TECHNICAL ASPECTS
Fluoroscopy, CT

23. TECHNICAL ASPECTS.. Drugs
• Long acting Corticosteroids
(CS): Altim®
• Moderated long acting CS
– Prednisolone acetate
– Dexaméthasone acétate
– Depomedrol®
(Methylprednisolone acetate).
• Anaesthesics : Xylocaïne 1%®
– Local anaesthesia, Block test.
– With CS in foraminal, facet
lumbar infiltration
– Not in cervical

24. CERVICAL FORAMINAL & FACET
INFILTRATIONS
Iatrogenic risk
(proximity of spinal cord
and vertebral arteries)
Importance of the anatomy

25. Cervical Facet Injection
Complications
• Vertebral artery puncture
• Motor and sensory block
• Phrenic and recurrent
laryngeal nerve paralysis
• Spinal cord trauma
• Spinal anesthesia
• Dural puncture
• Intravascular injection
• Chemical meningitis
• Hematoma formation
• Pneumothorax
• Infection

26. CERVICAL FACET JOINT
INFILTRATION
Best performed under CT
Indications:
Degenerative arthritis:
- osteo-radicular conflict
- segmental instability

27. INFILTRATION OF
C1-C2 LATERAL JOINTS

28. LUMBAR INFILTRATIONS
TECHNICAL ASPECTS
Postero-lateral approach

29. 29
Lumbar Facet
Postero-lateral approach

30. Lumbar Facet
Direct posterior approach

31. Direct posterior approach

32. Facet Joint Capacity
Facet joints have been shown to hold up to a
maximum of 1–2 mL of injected fluid by
anatomical studies.
Above 2 ml, rupture of the joint capsule occurs
and a resultant extravasation into the back and
epidural space lead to non-specific therapeutic
effects
Keeping in mind that contrast, steroid and local
anesthetic must subsequently be introduced.

33. Facet Joint Capacity

34. Right L5–S1 facet injection with
guided fluoroscopy

35. FACET JOINT INFILTRATION
Radio-guidance Indications
• Diagnostic test
• Degenerative arthritis: (osteo-radicular conflict, articular
synovitis on arthrosic arthropathy, Segmental instability)
• Synovial cyst:
Possibility of calcifications with Altim®

38. Facet joint injection in LBP
is its continued use justified?
The injection of local anaesthetic and/or
steroids into the facet joint is used
worldwide treating patients facetogenic
back pain;
However, the effectiveness of this therapy for
short- and long-term pain relief requires
evaluation

39. CONCLUSION
Spinal infiltrations are the last step in the
medical treatment before surgery.
Radioguidance is obligatory in cervical and
relative in lumbar peri-radicular infiltrations
Few reported complications should not
challenge the use of this technique.

40. Thank You